Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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218 Section III • The Esophagus

4. CLOSING

◆ In repairing the diaphragm, the gastric or jejunal interposition is secured to the crura with

interrupted sutures. The remainder of the diaphragm is closed with interrupted mattress

sutures. A chest tube should be placed into the pleural space near the anastomosis to ensure

adequate ﬂ uid drainage. The left lung is reexpanded and the costal cartilages are left to ﬂ oat

free. Tissue and skin are closed according to surgeon preference.

◆ Total gastrectomy with descending colon graft: Whereas the stomach is better than the colon

as an esophageal substitute, the colon may be used if the stomach is not a viable option

because of prior surgery or tumor extension. The descending colon is preferred to the ascend-

ing colon, because the smaller lumen is more similar in diameter to the esophagus. However,

the inferior mesenteric artery that supplies the descending colon is more likely to have athero-

sclerotic disease than other mesenteric vessels (Figure 18-16).

◆ After the surgeon thoroughly explores the abdomen for metastases, the length of the re-

quired graft should be measured. The middle colic artery should be clamped with a bulldog

clamp to evaluate the adequacy of collateral circulation.

◆ The descending colon is prepared by mobilizing the splenic ﬂ exure and separating the

attached omentum. The remaining colon is reanastomosed and the mesentery is reapproxi-

mated (Figures 18-17 and 18-18).

Middle

colic artery

Transverse colon

Left

colic artery

Descending

colon

Superior

mesenteric

artery

Incision

Inferior

mesenteric

artery

FIGURE 18 –16

Incising lateral

peritoneum to

mobilize

descending colon

FIGURE 18 –17

CHAPTER 18 • Esophagogastrectomy 219

Dividing descending colon

with GIA stapler

Descending colon

Transverse colon

FIGURE 18 –18

220 Section III • The Esophagus

◆ The proximal end of the anastomosis may be performed ﬁ rst to measure the length of the

graft more accurately (Figure 18-19). The colon is passed along the posterior mediastinum,

which is the shortest route between the stomach and the esophagus (Figure 18-20). The

substernal and transpleural routes are also secondary possibilities but may result in greater

kinking of the graft and subsequent emptying problems (Figures 18-21 and 18-22). The

proximal anastomosis may be hand-sewn in two layers or stapled (Figure 18-23). The

distal anastomosis between the proximal jejunum and colon is closed with an EEA stapler

(Figure 18-24).

Descending colon

Transverse colon

Left

colic artery

FIGURE 18 –19

Text continued on p. 225

CHAPTER 18 • Esophagogastrectomy 221

Heart

Esophagus

Substernal route

Abdominal aorta

Duodenum

Jejunum

Colon

Posterior

mediastinal

route

Esophagus

Heart

Abdominal aorta

Duodenum

Jejunum

Colon

FIGURE 18 –20

FIGURE 18 –21

222 Section III • The Esophagus

Left lung

Transpleural route

Esophagus

Right lung

Heart

FIGURE 18 –22

CHAPTER 18 • Esophagogastrectomy 223

Colon

Esophagus

Reinforcing anastomosis

of colon and esophagus

with interrupted sutures

Securing colon and esophagus

with running sutures

FIGURE 18 –23

224 Section III • The Esophagus

Proximal jejunum

Distal end

of colon

FIGURE 18 –24

CHAPTER 18 • Esophagogastrectomy 225

◆ The graft should be sutured to the crus of the diaphragm to avoid migration of the colon

into the thoracic cavity. The remainder of the closure is carried out as described previously

(Figure 18-25).

◆ Total gastrectomy with ascending colon graft: The ascending colon may be used if the

descending colon has been affected by severe diverticular disease, atherosclerotic disease of

the inferior mesenteric artery, or splenic vein thrombosis that extends to the inferior mesen-

teric vein.

Descending colon

Esophagus

Descending

colon

Sigmoid colon

Ascending colon

Duodenum

FIGURE 18 –25

226 Section III • The Esophagus

◆ The blood supply of the right colon from the marginal artery should be inspected by

clamping the ileocolic and right colic arteries. The ascending colon is harvested, leaving the

marginal artery intact (Figure 18-26).

Left

colic artery

Middle

colic artery

Descending

colon

Superior

mesenteric

artery

Transverse colon

Incision

FIGURE 18 –26

CHAPTER 18 • Esophagogastrectomy 227

◆ A section of ileum and the ileocecal valve may be included as part of the graft, because the

size of the ileum matches well with that of the esophagus and because the valve may pro-

vide some protection against reﬂ ux. However, reﬂ ux esophagitis is unusually high in the

neck and the valve may result in mild obstruction.

◆ After measuring out the length of colon needed, the surgeon divides the ascending colon

with a GIA stapler and reanastomoses the remaining colon. The graft is rotated and the

proximal end is brought into the neck for the anastomosis. The distal anastomosis can be

performed with an EEA stapler or a side-to-side stapled technique. The closure is performed

as described previously (Figure 18-27).

Ascending colon

Esophagus

Descending

colon

Transverse colon

Sigmoid colon

Ileum

Duodenum

FIGURE 18 –27